DECLARATION OF CONFLICT OF INTEREST

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1 DECLARATION OF CONFLICT OF INTEREST

2 The Management of Syncope remains a challenge: Clues from the History Richard Sutton, DSc Emeritus Professor of Cardiology Imperial College, St Mary s Hospital, London, UK

3 The Management of Syncope Richard Sutton s potential Conflicts of interest are: Consultant to Medtronic Inc. Recipient of research grants from Medtronic Inc. Recipient of Honoraria from St Jude Medical Shareholder in ACSI

4 Syncope: Definition a symptom which is a loss of consciousness that is: relatively sudden transient self-terminating usually rapid recovery due to inadequate cerebral perfusion most often triggered by a fall in systemic arterial pressure

5 Causes of True Syncope Neurally- Mediated Reflex Orthostatic Cardiac Arrhythmia Structural Cardio- Pulmonary 1 VVS CSS Situational Cough Postmicturition Others 2 Drug-Induced ANS Failure Primary Secondary 3 Bradycardia Sinus pause/arrest AV block Tachycardia VT SVT Long QTS Unexplained Causes = Approximately 10% 4 Aortic Stenosis HCM Pulm HBP/ Embolism Aortic Dissection MI 60% 15% 10% 5%

6 Syncope: Epidemiological Data 40% population experience syncope 1 1-6% of hospital admissions 2 Approx 1% of ED visits per year 3,4 10% of falls in elderly due to syncope 5 Injuries: 6% major, 29% minor 1 Reflex syncope low mortality; CV dis. high 6 Increasing ED,IP,OP,office visits 7 US costs >2.4 billion $ 8 Huge impact of syncope on Quality of Life 9 1Kenny RA, et al. eds. The Evaluation and Treatment of Syncope. Futura;2003: Kapoor W. Medicine. 1990;69: Brignole M et al. Europace 2003; 5: Blanc J-J et al Eur Heart J 2002; 23: Campbell A, et al. Age and Ageing. 1981;10: Soteriades ES et al. N Engl J Med 2002; 347: Nat. Hosp. Amb. Med C. 8Benjamin C. et al. Am J Cardiol 2005; 95: Linzer M. J Gen Int Med

7 Evaluation of Syncope Two important texts have been used throughout the preparation of this presentation 1. Moya A. et al Eur Heart J 2009; 30: Brignole M, Benditt DG. Syncope: an evidence based approach. Springer-Verlag London 2011.

8 Initial Evaluation of Syncope History including from a witness Physical examination Was it Syncope? Is Heart disease present?

9 Evaluation and Management of Syncope Using the History to its maximum effect in management of the patient To make a diagnosis To separate syncope from other causes of LoC To stratify risk To treat the patient

10 Evaluation of Syncope History (combined with physical examination, 12 lead ECG and standing BP) is the most powerful tool yielding a diagnosis in about 40% (1,2) In contrast, laboratory tests often add little Useful tests are CSM, ILR and tilt Almost useless tests are Brain scans and EEG EE EEEEE 1,2 EGSYS Study Eur Heart J 2006;27:76-82 and Europace 2010;12;

11 Syncope: Clues from the History History from the patient and a witness. No excuse that a witness did not come to the consultation. Use mobile phone. Where, when, what happened at the beginning, before syncope and after syncope? Was there injury? Was there incontinence? Details, details details From the witness: what was observed before syncope, during and afterwards. Details, details, details to build up a complete picture

12 Syncope: Clues from the History Questions about circumstances just prior to the attack Position: standing, sitting, lying Activity: change posture, ex, situational Predisposing factors: crowds, heat, after meals, prolonged standing, fear, pain, neck movement

13 Syncope: Clues from the History Questions about onset of the attack Nausea, Vomiting Abdominal discomfort Feeling of cold Sweating Pain in the back at shoulder level Palpitations Blurred vision Dizziness

14 Syncope: Clues from the History Questions about the attack itself from the witness Way of falling, crumpling, falling, direction of fall Skin colour and its evolution Duration of LoC and the whole attack Breathing pattern, normal, laboured, fast Movements, type, onset in relation to LoC/fall, duration Tongue biting, tip, sides Association with an accident

15 Syncope: Clues from the History Questions about recovery from the attack Nausea, vomiting Abdominal discomfort Feeling of cold Sweating Confusion, how rapidly did orientation occur Duration of post attack malaise Muscle aches, other pains Palpitations Incontinence

16 Syncope: Clues from the History Questions about background Family history of sudden death/fainting Known heart disease Previous neurological disease Metabolic disorders Diabetes, Alcohol Medication esp. Diuretics, Hypotensives, QT prolonging agents, Anti-epileptics Number of attacks, over what period, age of onset

17 Syncope: Clues from the History Historical features suggestive of specific causes of syncope 1. Reflex Syncope Long history of attacks (>3 yrs) Related to emotion (fear,pain,blood etc) Prolonged standing, crowds, warmth Nausea, vomiting, abd pain, sweating, cold During or shortly after a meal After exertion Head rotation or pressure in region of CS

18 Syncope: Clues from the History Historical features suggestive of specific causes of syncope 2. Orthostatic Hypotension After standing up Pain in the back at shoulder level Related to start/dose change of hypotensive or diuretic After exertion

19 Syncope: Clues from the History Historical features suggestive of specific causes of syncope 3. Cardiac Syncope During exercise Absence of prodrome Preceded by palpitation Family History of sudden death Chest pain EGSYS Study Heart 2008;94: YS

20 Syncope: Clues from the History Historical features suggestive of specific causes of syncope 4. Psychogenic Pseudosyncope/Pseudoseizure Very frequent episodes Young female Active fall Long unconscious period Difficult family background Probably started with Vasovagal Syncope Injury rare ESC Task Force Eur Heart J 2009;30: YS

21 Loss of consciousness: diagnostic flow Complete? Yes, may be syncope No, consider: Transient, short duration? Falls TIA, stroke Dizziness Psychogenic Drop attack Yes, may be syncope No, consider: Coma Intoxication Rapid onset? Yes, may be syncope No, consider: Recovery spontaneous, complete and prompt? Metabolic Intoxications TIA, stroke Psychogenic Yes, may be syncope No, consider: Epilepsy Loss of postural tone? Yes, may be syncope No, consider: Epilepsy Syncope likely

22 Stratification: Syncope Risk Is in-hospital evaluation needed? Primary concerns: Is there an immediate mortality risk? Is physical injury (e.g., falls risk) likely? Is required treatment determining in-hosp. stay? Currently many syncope patients undergo in-hospital evaluation Admission rate in US is ~36% Many admissions could be avoided by: Better risk stratification Availability of syncope management units

23 Hospital Admission for Diagnosis or Treatment Strongly Recommended Admission for Diagnosis Suspected or known structural heart disease ECG abnormalities suggestive of arrhyhmic syncope Syncope during exercise, Syncope causing severe injury Family history of sudden death Strongly Recommended Admission for Treatment Cardiac arrhythmias, Syncope 2 structural cardiac or cardiopulmonary diseases When pacemaker implantation is planned Occasionally may need to be Admitted Patients without heart disease but sudden onset of palpitations shortly before syncope Syncope in supine position, Frequent recurrent episodes when there is a high suspicion of cardiac syncope ESC Syncope Task Force 2004/9

24 Treatment of Syncope: Clues from the History A diagnosis of Vasovagal syncope can be made from the History and the patient treated appropriately. Likewise Situational Syncope. Orthostatic Hypotension due to medication can be made from the History and the patient treated appropriately. Neurological causes of OH and cardiovascular causes of Syncope typically require examination and investigation for a diagnosis.

25 Conclusions The History is the most important part of the evaluation. The History remains the most powerful tool available for assessment. The History reveals the mechanism of syncope in about 40% of patients presenting. The History includes that from a witness. The History is very demanding of the Physician but also very rewarding.